Study Points

Renal Disease and Failure

Course #34232 - $40 • 10 Hours/Credits

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. A common marker of chronic kidney disease (CKD) is

    AN OVERVIEW OF RENAL DISEASE

    A common marker of CKD is proteinuria, which is first detectable as microalbuminuria (i.e., >30 mg albumin in a 24-hour urine collection). Due to the difficulty of measuring 24-hour urine protein excretion, proteinuria is usually screened using dipstick or a spot urine albumin-creatinine ratio. Other indicators include abnormal urine sediment or abnormal imaging studies.

    Click to Review
  2. The two leading causes of end-stage renal disease (ESRD) are

    AN OVERVIEW OF RENAL DISEASE

    The two leading causes of ESRD are diabetes (44% of new patients) and hypertension (29% of new cases) [11]. New cases of ESRD with diabetes or hypertension listed as the primary cause had been rising rapidly since 1980, but each has declined from 2010 to 2013 [12,13]. Other less common causes of ESRD include glomerulonephritis, interstitial nephritis, autosomal dominant polycystic kidney disease (the leading genetic cause), and collagen vascular disease. Due to the prevalence of kidney transplantation, post-transplantation kidney disease has become the fourth largest cause of ESRD in the United States; however, these patients are reported within their original disease category for epidemiologic purposes [14]. New cases of diabetic ESRD are expectedly higher with increasing age in all racial groups, but generally stable or only slightly higher among younger individuals [10]. Statistically, non-whites are four times more likely to require dialysis. Compared with white patients, the prevalence of ESRD per million is 9.5 times greater in Native Hawaiians/Pacific Islanders, 3.7 times greater in African Americans, 1.5 times greater in American Indians/Alaska Natives, and 1.3 times greater in Asian Americans [10]. The cost of treating ESRD was $35.4 billion in 2016 [10].

    Click to Review
  3. The leading genetic cause of ESRD in the United States is

    AN OVERVIEW OF RENAL DISEASE

    The two leading causes of ESRD are diabetes (44% of new patients) and hypertension (29% of new cases) [11]. New cases of ESRD with diabetes or hypertension listed as the primary cause had been rising rapidly since 1980, but each has declined from 2010 to 2013 [12,13]. Other less common causes of ESRD include glomerulonephritis, interstitial nephritis, autosomal dominant polycystic kidney disease (the leading genetic cause), and collagen vascular disease. Due to the prevalence of kidney transplantation, post-transplantation kidney disease has become the fourth largest cause of ESRD in the United States; however, these patients are reported within their original disease category for epidemiologic purposes [14]. New cases of diabetic ESRD are expectedly higher with increasing age in all racial groups, but generally stable or only slightly higher among younger individuals [10]. Statistically, non-whites are four times more likely to require dialysis. Compared with white patients, the prevalence of ESRD per million is 9.5 times greater in Native Hawaiians/Pacific Islanders, 3.7 times greater in African Americans, 1.5 times greater in American Indians/Alaska Natives, and 1.3 times greater in Asian Americans [10]. The cost of treating ESRD was $35.4 billion in 2016 [10].

    Click to Review
  4. What is the annual average percentage of acute kidney injury (AKI) in the Medicare population?

    AN OVERVIEW OF RENAL DISEASE

    AKI is primarily a disease of hospitalized patients and often is the result of pre-existing chronic kidney disease [10]. AKI in the Medicare population has reached an annual average of approximately 4.7%, compared with 1.5% in 2005 [10]. AKI rates are significantly associated with aging and with black/African American race [10]. The most common causes of AKI vary according to pathophysiology, but possible etiologies include trauma, dehydration/volume depletion, tubulointerstitial disease, glomerulonephritis, and obstruction [2,7].

    Click to Review
  5. The most common type of AKI according to pathophysiology is

    AN OVERVIEW OF RENAL DISEASE

    The pathophysiology of AKI depends on the site of occurrence. Prerenal AKI, the most common type, is caused by renal hypoperfusion (most likely from dehydration) [15]. Intrarenal or intrinsic AKI, the result of damage to the renal parenchyma, may be a result of prolonged prerenal AKI (leading to acute tubular necrosis), toxins, interstitial disease, vascular disease, or acute glomerular disease [15]. Postrenal (obstructive) AKI results from physical obstruction of urine outflow and may be caused by neoplasm, prostatic enlargement, bladder dysfunction, or nephrolithiasis [2,15,16].

    Click to Review
  6. Suspicion for mild renal disease should be based on

    CLINICAL PRESENTATION

    The clinical presentation of CKD is often subtle, and symptoms are uncommon with a GFR greater than about 35 mL/min/1.73 m2. Therefore, suspicion for mild renal disease should be based on recognition of the primary pathologic mechanism responsible for renal injury, particularly in patients with diabetes and/or hypertension. It is equally important to begin early screening for the complications of renal disease to prevent morbidity and to establish a credible baseline for the individual patient.

    Click to Review
  7. The most important tool in monitoring patients with suspected and diagnosed renal failure is

    DIAGNOSIS

    The most important tool in monitoring patients with suspected and diagnosed renal failure or those at risk for developing renal disease is dipstick urinalysis, which should be performed at virtually every office visit. Urine dipstick testing is highly specific (although false positives do occur) but less sensitive than quantitative testing. The presence of proteinuria should alert the clinician to perform a full 24-hour urine analysis for protein and creatinine clearance (Table 3). All patients with diabetes who are negative for macroscopic proteinuria on dipstick testing should have laboratory testing for microalbuminuria, as early identification and treatment can improve prognosis. This testing should be initiated at the time of diagnosis for patients with type 2 diabetes and within two years of diagnosis for patients with type 1 diabetes [18].

    Click to Review
  8. Intrarenal AKI may be recognized by a distinctive presentation of

    DIAGNOSIS

    Urinalysis is highly diagnostic in differentiating between AKI and CKD. Prerenal AKI is usually accompanied by urine osmolality of more than 500 mOsm/kg, specific gravity of more than 1.020, and hyaline casts. Intrarenal AKI results in a urine osmolality of approximately 300 mOsm/kg, with a specific gravity of around 1.010, tubular casts, tubular cells, and a distinctive brownish, muddy appearance of the urine due to brown granular casts [17,25].

    Click to Review
  9. Which of the following factors indicates an increased risk of advancement to higher stages of kidney disease?

    MANAGEMENT OF CHRONIC RENAL DISEASE

    Almost all patients with stage 1 and stage 2 CKD are managed in primary care. Stage 1 CKD is kidney disease with normal kidney function. Kidney function in stage 2 is 60% to 90% [26]. The emphasis for these patients is identifying and managing risk factors, monitoring progression of renal impairment, and beginning patient education. It is important to remember that the risk of cardiovascular events is higher in patients with early CKD than advancement to dialysis or kidney transplantation [26]. Therefore, interventions to address cardiovascular risk factors are warranted, including increased physical activity, dietary changes, smoking cessation, and possibly pharmacologic treatment of hyperlipidemia or hypertension. Factors that indicate an increased risk of advancement to higher stages of kidney disease include [26]:

    • Proteinuria (albumin-to-creatinine ratio >70 mg/mmol or protein-to-creatinine ratio >100 mg/mmol)

    • Hematuria of renal origin

    • Declining GFR (Loss of 5 mL/min/1.73 m2 over one year or less or loss of 10 mL/min/1.73 m2 over five years or less)

    • Young age at diagnosis

    • Family history of renal failure

    • Hypertension that is difficult to control

    Click to Review
  10. For patients with stage 1 or 2 renal disease, cardiovascular risk should be assessed

    MANAGEMENT OF CHRONIC RENAL DISEASE

    Cardiovascular risk should also be assessed and addressed annually. Patients should be counseled regarding smoking, exercise, and lifestyle. Cholesterol-lowering therapy should be considered in patients with evidence of macrovascular disease or with an estimated 10-year risk of cardiovascular events ≥20% [26].

    Click to Review
  11. The leading cause of death among patients with ESRD is

    MANAGEMENT OF CHRONIC RENAL DISEASE

    While cardiovascular complications are recognized as the leading cause of death among patients with ESRD, accounting for more than 50% of deaths in the first year of dialysis, studies have shown that even mild-to-moderate renal disease (defined as an elevated serum creatinine between 1.2 mg/dL and 1.4 mg/dL) is an independent risk factor for cardiovascular events [4,5,34]. A meta-analysis of 38,000 patients revealed a 19% to 21% increase in the need for thrombolytic therapy in patients with a GFR less than 70 mL/min/1.73 m2 compared to patients with normal GFR [4]. A GFR less than 60 mL/min/1.73 m2 is an independent risk factor for heart failure. The mortality rate for patients with ESRD is more than 20% per year, making the prevention of cardiovascular complications the utmost priority [34].

    Click to Review
  12. The use of angiotensin-converting enzyme (ACE) inhibitors has been shown to be beneficial in patients with

    MANAGEMENT OF CHRONIC RENAL DISEASE

    Adequate blood pressure control has been proven beneficial in patients diagnosed with CKD [34]. Ideally, blood pressure should be reduced to less than 130/85 mm Hg [8]. The United Kingdom Prospective Diabetes Study showed benefit of even lower systolic pressures, with reduction in macrovascular complications in patients with diabetes continuing to systolic pressures as low as 114 mm Hg [36]. The use of ACE inhibitors and ARBs has also been shown to be beneficial in patients with diabetic nephropathy and for those with nondiabetic renal disease and proteinuria [36,37,38,39,40,41,42]. A meta-analysis suggested that ACE inhibitor therapy may provide superior benefit over ARB therapy, with a 10% reduction in all-cause mortality [43]. However, the selection of one agent over another will also take into account patient-specific factors (e.g., cost, potential for side effects). Simultaneous treatment with an ACE inhibitor and an ARB is not recommended, as this has been shown to worsen kidney function [5,44,45,46,47]. ACE inhibitors and ARBs should be used cautiously in patients at risk for hyperkalemia and should be avoided in patients with renal artery stenosis unless prescribed by a renal specialist, in which case close monitoring of renal function is absolutely essential [17,28].

    Click to Review
  13. Patients with diabetes and CKD should have a low-density lipoprotein (LDL) goal of less than

    MANAGEMENT OF CHRONIC RENAL DISEASE

    Hyperlipidemia is both a complication of CKD and a potential factor in the progression of the disease [8]. Lowering LDL cholesterol to achieve National Cholesterol Education Program goals (i.e., LDL less than 70 mg/dL) in patients with CKD is recommended [56]. The LDL target for any patient with diabetes and CKD is the same as for a patient without diabetes. A number of agents are available for the treatment of lipid disorders, although most have dosing limitations dependent on the degree of renal impairment present.

    Click to Review
  14. Patients with CKD should limit daily phosphorus intake to

    MANAGEMENT OF CHRONIC RENAL DISEASE

    DIETARY RECOMMENDATIONS FOR ADULT PATIENTS WITH CHRONIC RENAL FAILURE WHO ARE NOT ON DIALYSIS

    NutrientRecommendation
    Protein0.6–0.8 g/kg/day
    Calories35 kcal/kg/day
    Phosphorus0.8–1.2 g/day
    Calcium1.2–1.6 g/day
    Sodium1–3 g/day
    Potassium<60 mEq/day (restricted if serum potassium level is elevated or urinary output is <1 L/day)
    Click to Review
  15. Which of the following medications require dosage adjustment in patients with renal failure?

    MANAGEMENT OF CHRONIC RENAL DISEASE

    DRUGS REQUIRING DOSAGE ADJUSTMENT IN CHRONIC RENAL FAILUREa

    Antibiotics
    NSAIDs
    Digoxin
    Phenobarbital
    Opioids
    Antiarrhythmics
    Antihypertensives
    Antifungals
    Antivirals
    Librium
    Lithium carbonate
    aAlways consult the manufacturer's instructions when prescribing any drugs for patients with chronic renal failure.
    Click to Review
  16. Stage 4 CKD may require the use of exogenous erythropoietin to manage

    MANAGEMENT OF CHRONIC RENAL DISEASE

    Erythropoietin production is usually normal in patients with GFR rates greater than 20 mL/min/1.73 m2. However, the CBC should be monitored. If the hematocrit level falls to less than 32% (the level at which erythropoietin production is stimulated), serum erythropoietin levels should be assessed to determine the cause of the anemia. If serum erythropoietin stays low, exogenous erythropoietin should be given. To avoid transfusion-related hepatitis B (as well as the need for increased infection control precautions during hemodialysis), immunization should be given to patients who are antibody negative. Follow-up serology (i.e., hepatitis B surface antibody and hepatitis B surface antigen) should also be obtained, as many uremic patients seem to have problems mounting a demonstrable immune response after immunization [70].

    Click to Review
  17. ESRD is commonly defined as a glomerular filtration rate (GFR) less than

    MANAGEMENT OF CHRONIC RENAL DISEASE

    ESRD is commonly defined as a GFR of less than 15 mL/min/1.73 m2, and the basic hallmark of ESRD is uremia [4,84]. Uremic toxins are the byproducts of protein metabolism; in patients with ESRD, the toxins are not eliminated by the kidneys and begin to accumulate [4]. Severe uremia necessitates the use of dialysis to remove uremic toxins and prevent or control complications.

    Click to Review
  18. For adults with ESRD who are receiving hemodialysis, the recommended maximum daily intake of protein is

    MANAGEMENT OF CHRONIC RENAL DISEASE

    DIETARY RECOMMENDATIONS FOR ADULTS WITH END-STAGE RENAL DISEASE ON DIALYSIS

    NutrientRecommendation for HemodialysisRecommendation for Peritoneal Dialysis
    Protein1.1–1.4 g/kg/day1.2–1.5 g/kg/day
    Calories30–35 kcal/kg/day25–35 kcal/kg/day
    Phosphorus<17 mg/kg/day<17 mg/kg/day
    Calcium1.0–1.8 g/day1.0–1.8 g/day
    FluidDaily urinary output + 500–750 mL/day2–3 L/day based on weight and blood pressure
    Sodium2–3 g/day3–4 g/day based on weight
    Potassium40 mg/kgUnrestricted unless elevated
    Click to Review
  19. Hemodialysis can be provided via

    DIALYSIS

    Hemodialysis can be provided via three major different types of access: an AV fistula, an AV graft, or a temporary venous catheter. The NKF endorsed a goal for at least 65% of all patients on hemodialysis to have a working AV fistula by 2009, but this goal was not met [90]. As of 2017, reporting institutions dialyzed 62.8% of all patients on hemodialysis via AV fistulas [10].

    Click to Review
  20. Patency of the arteriovenous fistula can be assessed by

    DIALYSIS

    Fistula patency can be assessed by palpation of "thrill" and auscultation of bruit. A palpable motion in the surface of the fistula and a bruit when a stethoscope is placed over the fistula should both be present. The bruit should be loudest at the arterial side of the fistula. Patients found to have nonpatent grafts should be referred immediately to interventional radiology, as patency can often be restored by the use of antithrombotics (e.g., tissue plasminogen activators) and/or balloon angioplasty. Unfortunately, the use of contrast medium is usually necessary in order to restore patency. In these cases, the patient should be dialyzed within 24 hours of receiving the contrast. If the patient is to receive dialysis immediately after angioplasty, catheters may be left in place so it is not necessary to recannulate immediately after the procedure. If the patient is to return the following day for dialysis, temporary catheters should be removed to prevent potentially deadly hemorrhage. At no point should any patient with ESRD receive gadolinium-based contrast dye due to the risk of nephrogenic systemic fibrosis. Postexposure dialysis does not decrease the risk of developing nephrogenic systemic fibrosis in at-risk patients.

    Click to Review
  21. Which of the following is a contraindication to renal transplantation?

    RENAL TRANSPLANTATION

    The indication for transplantation is ESRD, or a GFR of <15 mL/min/1.73 m2 [8]. In recent years, the process for selection of kidney transplant has liberalized, with larger numbers of elderly patients being accepted for transplantation. In 1991, 30% of kidney transplant recipients were older than 50 years of age; by 2016, this number had increased to more than 70% [10]. Transplant counts for recipients 65 years of age and older have been steadily increasing [10]. Guidelines for selection of patients for transplantation vary from program to program. Generally, metastatic disease or severe pulmonary or heart disease are exclusionary factors. Human immunodeficiency virus (HIV) is no longer considered an absolute contraindication, and studies have shown that patients with ESRD and HIV nephropathy have an increased life expectancy when treated with transplantation versus dialysis [103].

    Click to Review
  22. In the United States, the median adult wait time for a cadaver kidney is

    RENAL TRANSPLANTATION

    Allocation of all transplants in the United States is managed by the United Network for Organ Sharing (UNOS). Kidney transplant guidelines place the highest considerations on histocompatibility and time spent on the transplant list [104]. Children suffering from ESRD will lose growth (and possibly other milestones) while on dialysis, so they are given priority. The median adult wait time for a cadaver kidney is four years [10].

    Click to Review
  23. Which of the following has been shown to help prevent contrast-induced nephropathy in patients with CKD?

    USE OF CONTRAST MEDIUM IN PATIENTS WITH RENAL DISEASE

    The use of sodium bicarbonate infusion pre- and postexposure to contrast medium has also been shown to help prevent the incidence of CIN. In a 2004 study, 119 patients were randomized to receive either sodium bicarbonate or sodium chloride at a rate of 3 mL/kg for one hour prior to their procedure followed by 1 mL/kg for six hours postprocedure [113]. The study was ultimately halted early due to a lower rate of acute renal failure in the sodium bicarbonate group, and remaining patients all received sodium bicarbonate. Follow-up analysis showed that 8.4 patients needed to be treated with sodium bicarbonate to prevent one case of CIN [113]. Absolute data from the study showed that 13.6% of patients in the sodium chloride group developed acute contrast-induced nephropathy; in the bicarbonate infusion group, only 1.7% of patients developed acute contrast nephropathy [113]. A 2018 randomized, placebo-controlled trial assessed the efficacy of intravenous NAC for prevention of CIN following diagnostic and/or interventional procedures requiring administration of contrast medium [114]. A total of 222 patients were randomly assigned to receive either NAC or placebo. All patients received IV hydration with normal saline before and after catheterization. CIN occurred in 30 of the 222 patients (13.5%), including 9 of 108 (8.3%) in the NAC group and 21 of 114 patients (18.4%) in the control group. Elevated serum creatinine 10 to 15 days after administration of the contrast medium was associated with an increased risk of adverse events [114]. A retrospective cohort study conducted at the Mayo Clinic assessed the risk of CIN with the use of sodium bicarbonate, NAC, or a combination of the two [115]. Compared with no treatment, sodium bicarbonate alone was associated with an increased risk of CIN, while NAC alone or in combination with sodium bicarbonate did not significantly affect the incidence of CIN [115].

    Click to Review
  24. The most common form of renal disease in patients with HIV is

    HIV AND RENAL FAILURE

    While most clinicians do not generally think of renal failure as a consequence of HIV, in fact nephropathy is the most common form of renal disease in HIV-positive individuals [118]. Kidney disease is a fairly common complication of HIV disease, ranging from nephropathy to kidney injury due to antiretroviral therapy and prerenal AKI due to dehydration [118].

    Click to Review
  25. In a typical, uncomplicated pregnancy, which of the following renal changes occur?

    RENAL DISEASE AND PREGNANCY

    In even a typical, uncomplicated pregnancy, renal dynamics are affected. Renal plasma flow increases dramatically, and by the second trimester, GFRs can reach 150% of normal [135,136]. Accordingly, BUN and serum creatinine normally decrease. Blood pressure should fall in the first 24 weeks by approximately 10 mm Hg and return to normal levels by term [135]. Glucosuria also occurs in normal pregnancy due to changes in tubular function and decreased serum sodium levels (by approximately 5 mEq/L). Overall kidney size increases by approximately 1–1.5 cm, and the ureters dilate. This, coupled with changes in the pelvis, can lead to urinary stasis and an increase in urinary tract infections. Proteinuria up to 300 mg/day may occur even in normal pregnancy [135,136].

    Click to Review
  26. Pre-eclampsia is a syndrome of

    RENAL DISEASE AND PREGNANCY

    Pre-eclampsia is a syndrome of proteinuria and hypertension that affects up to 5% of all pregnancies, while eclampsia is the occurrence of seizures in a patient with pre-eclampsia [135]. Pre-eclampsia does not usually develop until after the 32nd week of pregnancy, but it may develop much earlier in patients with CKD or hypertension. Risks factors include prepregnancy hypertension, diabetes, and CKD. Management of pre-eclampsia begins with bed rest but can include use of antihypertensives. Methyldopa, labetalol, and hydralazine are generally used, although this indication is off label. ACE inhibitors are contraindicated in pregnancy and can cause fetal loss, and diuretics are usually avoided in euvolemic patients. Intravenous magnesium sulfate can be used to prevent seizures. After 32 weeks' gestation, worsening pre-eclampsia warrants early delivery; eclampsia always mandates immediate delivery [135,136].

    Click to Review
  27. In pregnancies after renal transplantation, fetal survival rates are

    RENAL DISEASE AND PREGNANCY

    Since 1958, more than 5,000 women have given birth post-transplant [140]. Women who previously were unable to conceive while undergoing dialysis often have a return of fertility after transplant, and up to 12% of all women of childbearing age may become pregnant [139]. Outcomes are generally quite good, with up to a 90% fetal survival rate [136]. Patients should be counseled that a properly planned and monitored pregnancy is possible, including preconception counseling by the transplant team. Recommendations for patients considering pregnancy include changing immunosuppressive regimens to limit dosages of prednisone and azathioprine and stopping mycophenolate mofetil and sirolimus six weeks prior to conception. Ideally, the patient should be two years post-transplant and in good health, with a serum creatinine level less than 2.0 mg/dL. There should be no recent or ongoing rejection, and patients should be normotensive and have minimal or no proteinuria [135,136].

    Click to Review
  28. When prescribing selective serotonin reuptake inhibitors to patients with CKD, the dose should

    MENTAL HEALTH AND RENAL DISEASE

    Treatment of nonsuicidal patients who are found to be appropriate for outpatient care usually begins with a selective serotonin reuptake inhibitor. These medications are preferred in renal disease due to their relatively benign side effect profile and their lack of renal clearance resulting in no need to modify dosage.

    Click to Review
  29. Chronic illness can be the source of ambiguous loss, which is defined as loss

    PATIENT AND FAMILY EDUCATION

    Chronic illness can be the source of ambiguous loss, which is defined as loss without the finality of death but also with no certainty that the person will return to his or her previous level of functioning [144]. The goal is not necessarily to eliminate this sense of loss, but rather to increase family tolerance and coping. After identifying the loss, the family would work collaboratively to make decisions regarding day-to-day care and activities. Depression, which is commonly experienced among caregivers, may also be viewed as symptomatic of ambiguous loss. Therefore, practitioners can help encourage caregivers to not assume all the burden of responsibility, but rather to delegate and distribute the work. This may mean obtaining respite assistance [144].

    Click to Review
  30. Hospice is generally approved for patients with ESRD who

    PATIENT AND FAMILY EDUCATION

    An end-of-life discussion is recommended in the presence of stage 4 or 5 CKD or ESRD [157,158,159]. Hospice is generally approved when patients with ESRD are not candidates for dialysis, have a creatinine clearance less than 15 mL/minute, and/or have a serum creatinine level greater than 8 mg/dL (or 6 mg/dL in patients with diabetes) [160]. Guidelines from the Renal Physicians Association note that prognosis should be fully discussed with all patients who have stage 4 or 5 disease or ESRD [158]. Clinicians should carefully prepare for the discussion of prognosis by reviewing the patient's medical record and talking to other healthcare professionals involved in the care of the patient [161]. Because there is variation among patients with regard to their desire for information, clinicians should follow the "ask-tell-ask" approach: ask the patient if he or she is willing to discuss prognosis; if yes, discuss the prognosis and then ask the patient to confirm his or her understanding [157,162]. When discussing prognosis, quantitative estimates are more understandable for patients and family than qualitative ones (e.g., "poor"), and general timeframes for survival should be given [157,162,163,164]. In addition, clinicians should emphasize that prognosis is determined by looking at large groups of patients and that it is harder to predict survival for an individual [157,158]. The discussion of prognosis is often not documented in the patient's record, but it should be [161].

    Click to Review

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.